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} <br /> SAN JOAQUIN LOCAL HEALTH 0151RICT <br /> OFFICE USE: 1601 E. Hazelton Aver tAkton, CA 95205 Permit No. '7&/06 6 <br /> Telephone (209) '466-6781 <br /> Date Issued 7-//- 7f <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> .This Permit Ex `ires l Year From Date Issued <br /> Complete In Triplicate <br /> Application is hereby .made to the San Joaquin Local. Health District for a permit .to .construct <br /> and/or install the work herein described. This application i.s made in compliance with San <br /> Joaquin County Ordinance No:, 1862 and the :Rules and .Regulat-ions of the San Joaquin.. Local Health <br /> os <br /> '�i s t r i.c t. f ..5 � <br /> ,T <br /> EXACT STREET ADDRESS�L? Y TOWN i <br /> Owner's Name '9 Phone <br /> Address City <br /> Contractor's Name PAeV41z,0 LicenseLZM/Sl Phoned - - 7 <br /> IS CERTIFICATE OF WORKMAN'S -CO"1PENSATIO�i--iNSURA"! E--ON -FILE WITH-SJLHD? YES - 1140 <br /> TYPE OF' WORK (Check) : NEW WELL Cn DEEPEN Cd PRECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT 0 OTHER 0 �. <br /> PUMP INSTALLATION ❑ PUMP REPAIR 0 PUMP REPLACEMENT L� <br /> k <br /> DISTANCE TO NEAREST: SEPTIC TANK` SEWER LINE�:5j- 4 PIT PRIVY <br /> SEWAGE DISPOAS L FIELQ<21 L CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LIN V00RIVATE ESTIC WELL622' t PUBLIC DOMESTIC WELL-= <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation Zk " <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Gravel Pack Depth of Grout Seal .---_ <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Instal ed by.- _ <br /> PUMP INSTALLATION: Contractor ' <br /> Type .of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑State Work Done' + <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure ` <br /> I hereby certify that I have prepared this application and that the work will be done in accordanc( <br /> with San Joaquin County Ordinances , State Laws , and Rules and -Regulations of the San Joaquin Local <br /> Health District. Home owner or licensed agent' s signature certifies the following: <br /> "I certify that in the performance of the work for which this permit is issued, I shall <br /> not employ any person in such manner as to become subject to Workman's Compensation <br /> laws of California. " <br /> I WILL C FORA AROUT S T 0 PRIOR TO GROUTING AND A FINAL INSPECTION. _ ` <br /> SIGNE �. TITLE: DATE: 16 <br /> DR W4 PL.OT PLTN ON REVS S SIDE <br /> FOR DEP RTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY 1A DATE <br /> ADDITIONAL COMMENTS: " <br /> PHASE II GROUT INSPECTION PHASE I I INAL INSPECTION <br />' INSPECTION BY DATE AVIA - INSPECTION BY DATE 7 <br /> f: <br /> 2M- <br /> LEH 1426 Rev. I2-77 <br /> - <br />